The education versus training and the skills versus competency debate

The essence of modern medical education lies in the ability of defining and developing its terminology, which all too often is used in a less than thoughtful and inappropriate manner. Educationalists place emphasis upon the concept of learning rather than teaching; learning which is specifically student centred and student directed learning rather than teacher centred didactic teaching. However within this change environment we still prefer to use the word training, as in vocational training, to describe a specific programme and aspire to levels of competency that hopefully match the learning outcomes of the programme. This article opens the debate on whether the satisfactory completion of a learning programme is sufficient (cf completion of vocational training) or whether we should be assessing the learner through levels of defined competency relevant to their professional career

Continuing professional development

It would be unlikely that many of today\'s practicing family doctors have not been involved in Continuing Medical Education (CME) activities. It would be equally unlikely, however, that these activities were part of any contextually structured educational plan towards professional development. Often driven by external need towards a reaccredidation procedure, CME can be seen as a burden upon the average practitioners working day, or more usually evening. The concept of Continuing Professional Development takes the practitioner away from these short-term goals and moves them into a planned educational environment. Using the principles of adult education, this article supports the concept of Continuing Professional Development and demonstrates the value to the practitioner of an educational activity that is both relevant and purposeful towards daily practice, hopefully equally beneficial to the practitioner and patient alike. This article considers some of the theory that underlies the change from Continuing Medical Education (CME) to Continuing Professional Development (CPD), the evidence for its effectiveness, and the ways in which CPD interacts with the processes of appraisal and assessment of medical practitioners.South African Family Practice Vol. 47(3) 2005: 5-

Encouraging reflective practice

As busy practitioners it becomes commonplace to look back over the day\'s professional activities. All too often, and despite a preponderance of positive interactions, the reflective eye reviews the negative aspects of daily activity and interrupts the intended social relaxation. Hence reflection in medical care is often seen as a negative act, without purpose and rarely connected to any true educational outcome. In this article, the authors\' present a positive picture of reflective practice and open the discussion of how it can become standard professional practice, leading to high quality care and encourage future learning. South African Family Practice Vol. 47(7) 2005: 5-

Feedback: The educational process of giving and receiving

The report of the Standing Committee on Postgraduate Medical Education in the United Kingdom stated in 1995 1 that “all those involved in teaching can contribute by creating a positive educational environment, helping learners to achieve their goals by providing support and constructive feedback… They need to understand more about the need for, and the ways of achieving feedback, appraisal, openness and trust.” Over a number of years, many surveys have shown that a lack of feedback is the most common complaint students, interns and registrars make about their teaching and training. In many ways it is the most serious, for feedback is essential to progression in learning. The purpose of this article is to describe the concept of feedback, its triangulation with effective teaching and learning and to demonstrate its potential in maximising any teaching activity that is encountered within practice. It will also explore how, because of its close proximity to appraisal, feedback may provide personal drive and motivation

Effective teaching through active learning

There can be very few practitioners whose daily working life is not involved someway in teaching or learning. Used in its broadest sense, we engage teaching everyday in our advice to patients, and conversely we learn from each of our patients. As we move inexorably towards compulsory reaccredidation for all practitioners, purposeful and effective continuing professional development takes over from the previously passive continuing medical education model. As Universities and Medical Schools recognise where most healthcare occurs and see the benefits of community-based education, increasing numbers of undergraduate and postgraduate students pass daily through our surgery doors. No doubt, the majority of busy practitioners see these activities as an increased workload rather than an opportunity, a stress factor rather than a possibility to develop in their personal lives. In this article, we wish to suggest how some of our daily practice activities can be seen as opportunities to teach and learn; how by using the principles of being an effective teacher, we can create learning situations for all. "Learning and teaching should not stand on opposite banks and just watch the river flow by; instead, they should embark together on a journey down the water. Through an active, reciprocal exchange, teaching can strengthen learning how to learn". Loris Malaguzz

The Education versus Training and the Skills versus Competency debate

The essence of modern medical education lies in the ability of defining and developing its terminology, which all too often is used in a less than thoughtful and inappropriate manner. Educationalists place emphasis upon the concept of learning rather than teaching; learning which is specifically student centred and student directed learning rather than teacher centred didactic teaching. However within this change environment we still prefer to use the word training, as in vocational training, to describe a specific programme and aspire to levels of competency that hopefully match the learning outcomes of the programme. This article opens the debate on whether the satisfactory completion of a learning programme is sufficient ( cf completion of vocational training) or whether we should be assessing the learner through levels of defined competency relevant to their professional career.SA Fam Pract 2004;46(10): 5-

Mentoring in medical practice

Previous articles in this series have defined words and concepts that guide our thinking in the areas of teaching and learning, set in the greater world of education; but what happens in the quiet and often lonely world of individual practice? As we reflect upon our pasts, many of us recognise that we have at some point in time engaged with a significant figure who has had a long term and positive influence on our personal development; someone who has the unusual and valuable qualities that mean that whatever else is happening to them personally, they maintain a genuine interest in at least one other person's development. All too frequently, this becomes an isolated event; a lost activity from which there is limited gain. This article explores how, as busy practitioners, we may think of using the principles implied in this experience and build upon them to facilitate a powerful and cost effective method that encourages personal development

Implementing a structured triage system at a community health centre using Kaizen

Background: More than 100 unbooked patients present daily to the Mitchell’s Plain Community Health Centre (MPCHC), and are triaged by a doctor, with the assistance of a staff nurse. The quality of the triage assessments has been found to be variable, with patients often being deferred without their vital signs being recorded. This leads to frustration, and a resultant increased workload for doctors; management is concerned with the medicolegal risk of deferring patients who have not been triaged in accordance with the guidelines; and patients are unhappy with the quality of service they receive. Aim: We set out to standardise the triage process and to manage unbooked patients presenting to the community health centre (CHC) in a manner that is medico-legally safe, cost efficient and patient friendly, using the Kaizen method. Methods: The principles of Kaizen were used to observe and identify inefficiencies in the existing triage process at the MPCHC. Findings were analysed and interventions introduced to improve outcomes. The new processes were, in turn, validated and standardised. Results: The majority of patients presenting to Triage were those needing reissuing of prescriptions for their chronic medication, and this prevented practitioners from timeously attending to other patients waiting to be seen. Reorganising of the process was needed; it was necessary to separate the patients needing triage from those requiring only prescriptions to be reissued. After the intervention, triage was performed by a staff nurse only, using the Cape Triage Score (CTS) method. Subsequent to the implementation of interventions, no patients have been deferred, and all patients are now assessed according to a standardised protocol. The reasons for patients requiring reissuing of prescriptions were numerous, and implementing countermeasures to the main causes thereof decreased the number of reissues by 50%. Conclusion: The Kaizen method can be used to improve the triage process for unbooked patients at the MPCHC, thereby improving the quality of services delivered to these patients. As the needs of the various CHCs differ quite widely across the service platform, the model needs to be adapted to suit local conditions

Approach to chest pain and acute myocardial infarction

Patient history, physical examination, 12-lead electrocardiogram (ECG) and cardiac biomarkers are key components of an effective chest pain assessment. The first priority is excluding serious chest pain syndromes, namely acute coronary syndromes (ACSs), aortic dissection, pulmonary embolism, cardiac tamponade and tension pneumothorax. On history, the mnemonic SOCRATES (Site Onset Character Radiation Association Time Exacerbating/relieving factor and Severity) helps differentiate cardiac from non-cardiac pain. On examination, evaluation of vital signs, evidence of murmurs, rubs, heart failure, tension pneumothoraces and chest infections are important. A 12-lead ECG should be interpreted within 10 minutes of first medical contact, specifically to identify ST elevation myocardial infarction (STEMI). High-sensitivity troponins improve the rapid rule-out of myocardial infarction (MI) and confirmation of non-ST elevation MI (NSTEMI). ACS (STEMI and NSTEMI/unstable angina pectoris (UAP)) result from acute destabilisation of coronary atheroma with resultant complete (STEMI) or subtotal (NSTEMI/UAP) thrombotic coronary occlusion. The management of STEMI patients includes providing urgent reperfusion: primary percutaneous coronary intervention (PPCI) if available, deliverable within 60 - 120 minutes, and fibrinolysis if PPCI is not available. Essential adjunctive therapies include antiplatelet therapy (aspirin, P2Y12 inhibitors), anticoagulation (heparin or low-molecular-weight heparin) and cardiac monitoring

Impact of transthoracic echocardiography at district hospital level

Background. The use of and demand for echocardiography (ECHO) has increased worldwide. In developed countries, this has nottranslated into improved access outside tertiary centres. Previous studies have favoured the appropriate use of ECHO over its clinicalimpact, limiting generalisability to resource-constrained settings.Objectives. To assess the impact of an ECHO service at district hospital level in Cape Town, South Africa.Methods. A prospective, cross-sectional study was performed. A total of 210 consecutive patients, referred to the ECHO clinic over a5-month period, were recruited. Transthoracic ECHO was evaluated in terms of its indication, new information provided, correlation withthe referring doctor’s diagnosis and subsequent management plan. Impact included the escalation and de-escalation of treatment, as wellas usefulness without a change in management.Results. The results show that 83.8% of the patients’ management was impacted on by echocardiography. Valvular lesions were themain indication. The most frequent contribution was information provided towards the diagnosis of heart failure and assessment aftermyocardial infarction. Of the echocardiograms, 56.2% confirmed the referring doctor’s diagnosis, yet were still associated with a significantimpact. The rational prescription of medication had the major impetus, followed by de-escalation of therapy and screening patients todetermine referral to a tertiary facility.Conclusion. ECHO has a positive impact on patient management outside tertiary settings, where the definition of impact appears to bedifferent. The value of a normal study, screening prior to upstream referral and usefulness irrespective of change have been established. Thisshould alert policy makers against restriction of access to ECHO and promote training of personnel in its use